Managed Long Term Care-MEDS
Readiness Reviews
Tom LoGalbo
Managed Care
IPRO
November 13, 2013
MEDS Readiness Reviews
Why?
 Encounter data submitted via MEDS is used by the
NYSDOH for a varietyy of purposes
p p
and activities
including:
● Risk adjustment rate payment methodology
● Service utilization monitoring
● Fraud and abuse monitoring
● Disease identification and monitoring
2
MEDS Readiness Reviews
Why (continued)
 The MLTC program has been steadily expanding, across the
various plan types.
● A number of new MLTC plans have either recently commenced operations and
have not yet submitted MEDS data, or have very recently started MEDS
reporting.
ti
 Therefore:
● IPRO , in conjunction with the DOH, developed a readiness review project for
th MLTC plans,
the
l
tto address
dd
the
th components,
t steps,
t
and
d corporate
t
infrastructure considered necessary for comprehensive and accurate MEDS
reporting.
● The p
principal
p component
p
of the p
project
j
was a survey,
y, administered to a sample
p
of new MLTC plans, and to those plans experiencing problems with MEDS
submissions.
3
MEDS Readiness Reviews
Survey components
 The survey included components on the following topics:
● Claims/encounter processing
● Claims/encounter lag time
● A breakout of services and how each are provided (internally or through
vendors/subcontractors)
● Mapping/conversion process to insure proper mapping to MEDS specifications
(where necessary and if applicable)
● Process for insuring that all pertinent data is uploaded to the MEDS system
4
MLTC MEDS Readiness
Claims/Encounter Processing
The survey addressed questions regarding:
 Process for tracking service authorizations
 Process for reconciling service authorizations to
claims/encounters
 Claims “time
time to process”
process results
 Claims quality audits
 Average claims/encounter lag time
 Claims/encounter data completeness studies
5
MLTC MEDS Readiness
MEDS Data Capture
The survey addressed the services specified in the MEDS MLTC
Reporting Guide, and for each, asked for plans’ responses to the
following:
a) Service coverage (yes/no)
b) How is the service provided (e.g. internally, vendor)
c) How documented (e.g. claim, encounter, internal log)
d) How invoiced (e.g. hours, visits)
e)) A
Are C
Category
t
off Service
S i codes,
d
P
Provider
id S
Specialty
i lt
Codes, Procedure Codes captured for MEDS
reporting?
6
MLTC MEDS Readiness
MEDS Reporting Process
The survey addressed the following related to the
MEDS reporting process:
a) The number of staff members involved in the process
b) Staff’s level of familiarity with the MEDS reporting requirements and the
MEDS MLTC reporting guide
c)) Software
S ft
utilized
tili d in
i th
the process
d) The role of subcontractors/vendors (if applicable)
e) Is the process different for each of the managed long term care reporting
lines?
7
MLTC MEDS Readiness
MEDS Reporting Process
The survey also addressed:
a) Letters /notifications from the NYSDOH regarding encounter
data reporting issues
b) Problems/concerns with MEDS submissions
.
8
MLTC MEDS Readiness
Summary of Findings
Internal Systems
a) All of the plans had established processes in place for
t ki service
tracking
i authorizations
th i ti
and
d reconciling
ili
authorizations to claims
b) Almost all of the surveyed plans were able to provide
time to process (TTP) results for claims and encounters.
Average TTP was calculated to be approximately 25 days
from receipt of claim/encounter.
c) Most of the plans were able to provide claims/encounter lag
results. Average lag was calculated to be 40-45 days from
service date.
Focused social worker interaction
assessment visits
Advance directive discussions made part of clinical
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MLTC MEDS Readiness
Summary of Findings-Continued
Internal Systems (Continued)
d)
Several of the newer plans were unable to provide claims lag
calculations.
e) Almost all of the surveyed plans indicated that claims quality
audits are conducted.
● Audit results were generally favorable
10
MLTC MEDS Readiness
Summary of Findings-Continued
MEDS Data Capture, MEDS Reporting
a) Some plans commented on specific provider issues
(e.g. not reporting with national standard billing codes, not
submitting DOH compliant reporting codes)
b)) Smaller p
plans expressed
p
concerns with MEDS data to the level
of detail necessary to fulfill required reporting requirements
c) Plans expressed challenges with capturing third party vendor
data (e.g. vision, dental, pharmacy) in a way that can be
reported for MEDS
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MLTC MEDS Readiness
Summary of Findings-Continued
MEDS Data Capture, MEDS Reporting
d) Newer plans expressed the need for assistance in interpreting
and understanding
nderstanding the response files generated from MEDS
submissions
e) IPRO and the DOH observed that a number of plans were not
aware off the
th DOH generated
t d validation
lid ti reports,
t or, were nott
reviewing these reports on a regular basis.
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For more information
Tom LoGalbo
(516) 326-7767 ext. 349
tl
[email protected]
lb @i
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